Lateral Collateral Ligament Injury Treatment (LCL Tears)

LCL tears
 Clive Brunskill / Getty Images 

Treatment of knee ligament injuries can be complicated, and the best treatment decision is often a subject of debate. This treatment decision may be influenced by a number of different factors.

Treatments may be affected by the type of injury, the severity of injury, the mechanism of injury, and the expectations for activities in the future. Not all ligament injuries of the knee are treated the same, and not all orthopedic surgeons treat injuries in the same way.

For this reason, people who injure their knee ligaments may find different treatment recommendations from different doctors. That does not mean one doctor is right and the other wrong, rather they are just different opinions about how to best manage these complex injuries.

What Is a Lateral Collateral Ligament Tear?

The lateral collateral ligament, or LCL, is one of the four major ligaments that supports the knee joint. The LCL is located on the outer side of the knee. LCL tears may occur as a result of a twisting type of injury or they may be the result of a direct blow to the inner side of the knee. LCL tears rarely occur as an isolated injury, and are much more commonly found in association with other damage inside the knee joint. When an LCL tear occurs, people tend to complain of sensations of instability or buckling of the knee especially with side-to-side cutting or pivoting movements.

Nonsurgical Treatment of LCL Tears

LCL tears are graded according to the severity of the injury. Grade 1 and grade 2 LCL tears involve damage to the ligament however there is not a complete disruption of the fibers of the entire ligament. In general, these injuries are managed with nonsurgical treatment.

Ideally, people who sustain grade 1 and grade 2 LCL injuries can begin early movement of the knee joint. Delayed movement tends to lead to stiffness of the joint.

While grade 1 and grade 2 LCL tears generally can be managed nonsurgically, they may occur in the setting of other ligament damage that does require surgical intervention. Again, the goal should be to get people moving their knee as quickly as possible. Therefore, surgery may be needed for joint stabilization of other ligament damage, even if the LCL is not completely torn.

Surgical Treatment of LCL Tears

When the lateral collateral ligament is completely torn, surgical treatment is generally recommended. Surgical treatment can either be performed to repair the damage to the ligament or reconstruct the lateral collateral ligament by creating a new ligament using tissue graft. A repair of the lateral collateral ligament is usually only possible when the ligament is torn off from the bone at either end of the ligament. These types of injuries, called avulsions of the ligament, occur when the ligament is torn from its attachment to the bone. In many situations, a small fragment of bone will be pulled off with the ligament at the time of the injury.

In these cases, thick, heavy suture material can be used to reattach the ligament to the bone where it was torn off.

When the damage occurs in the central portion of the lateral collateral ligament, typically the ligament will require reconstruction with the use of graft material. Different types of tissue graft can be used to reconstruct the damaged lateral collateral ligament. Options include obtaining tissue from the patient's body (autograft) or obtaining tissue from a donor (allograft). The advantage of allograft material is not having to cause any further damage to the injured person requiring reconstruction.

However, there are concerns about the possibility of disease transmission, as well as concerns about the strength of the graft tissue, and therefore some people prefer using their own tissue. Most commonly, a donor graft is used to reconstruct the lateral collateral ligament.

In order to perform a reconstruction there are various surgical techniques. Most often the lateral collateral ligament is reconstructed by attaching the graft to the end of the thigh bone (femur), weaving the graft through the top of the fibula (the smaller bone on the outside of the knee joint) and reattaching the end of the graft back up to the femur. This reconstruction allows for restoration of the normal anatomy of the lateral collateral ligament.

Results of Surgery

A number of studies have investigated the results of lateral collateral ligament reconstruction. While these injuries are relatively rare, and therefore these studies are small in comparison to analysis of other types of ligament injuries of the knee, they generally show the the results of surgery are overall quite good. People who undergo surgery have improved function, mobility, and less pain compared to people who have nonsurgical treatment for complete (grade 3) tears of the lateral collateral ligament. In addition, when people have associated injuries, such as ACL tears or posterolateral corner injuries, the results of surgical treatment of the lateral collateral ligament leads to improved results.

That said, there are some potential downsides. In one study that looked at professional football players, they found that athletes who were treated nonsurgically were just as likely to return to professional sports, and had a faster recovery than those managed surgically. In addition, these athletes were not exposed to the risks and potential complications of surgery. There is always a temptation to try to restore normal mechanics and stability to the knee joint, but ultimately the goal should be to return people to the activities they want to be able to do.  If the surgery does not improve either the short-term or the long-term function of the joint, then we need to question the possible benefits of surgical intervention.

Risks of Surgery

Knee ligament surgery has become very common, and the risks associated with surgical treatment are generally unlikely. People who have knee ligament surgery, including treatment of LCL injuries are most likely to experience complications including stiffness, decreased stability of the joint, and ongoing discomfort of the knee. Furthermore, people who sustain knee ligament injuries are more likely to develop arthritis of the joint later in life. These risks and complications exist regardless of whether or not surgery is the chosen treatment, and the risks may be diminished with surgical treatment. If arthritis develops in the knee joint later in life, additional surgical procedures, including possibly a knee replacement surgery, may ultimately become necessary.

Risks associated with surgery include infection and nerve injury. There is a large nerve called the peroneal nerve which is very close to the fibular attachment of the lateral collateral ligament. At the time of surgery, careful attention to protect that nerve needs to be undertaken. The peroneal nerve is important in helping to control mobility of the foot.This nerve controls the muscles that pole of the foot upwards.  It also provides sensation to the top of the foot.  People with damage to the peroneal nerve have a condition called "foot drop" which can interfere with their ability to walk normally and leads to numbness on the top of the foot.

A Word From Verywell

Knee ligament injuries are common sports related problems that occur in athletes. One of the major knee ligaments is the lateral collateral ligament, or the LCL. When an injury occurs to the lateral collateral ligament, treatment depends on a number of factors including the severity of the tear. In grade 1 and grade 2 injuries, nonsurgical treatment is generally the most appropriate treatment. In grade 3 injuries, when the ligament is completely torn, surgery is likely to be recommended. Surgery for a lateral collateral ligament injury typically involves a reconstruction using tissue graft to create a new ligament to take the place of the damaged ligament.

Sources:

Grawe B, Schroeder AJ, Kakazu R, Messer MS. "Lateral Collateral Ligament Injury About the Knee: Anatomy, Evaluation, and Management" J Am Acad Orthop Surg. 2018 Mar 15;26(6):e120-e127.

Geeslin AG, LaPrade RF. "Outcomes of treatment of acute grade-III isolated and combined posterolateral knee injuries: A prospective case series and surgical technique" J Bone Joint Surg Am 2011;93(18):1672–1683.